Module Five Milestone

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Southern New Hampshire University *

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215

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Mechanical Engineering

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Dec 6, 2023

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docx

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1 5-2 Final Project Milestone Three: CPT and E/M Coding Heather Corder Southern New Hampshire University HIM-215-X1505 Donna Leone October 2, 2022
2 5-2 Final Project Milestone Three: CPT and E/M Coding As stated in the previous milestone: Patient Lonnie Lates presented to the emergency room at Global Care Medical Center 5/10/XXXX, she was admitted the same day for Parkinson’s disease and to rule out cerebral vascular insufficiency. Her chief complaints were weakness and dizziness during the month prior to her admission and the day before admission she had falls at home as well as difficulty walking. Ms. Lates was discharged 5/14/XXXX to her home via one- way ambulance transportation with an office follow-up visit scheduled 5/17/XXXX at 12:40pm [ CITATION Cor22 \l 1033 ]. For the inpatient record we are working with for this milestone there are several CPT codes that apply. After reviewing I know that I will have codes for each of the following: the emergency room visit, the x-ray for the chest and left hip, the labs that were done and the EKG. The codes I chose are as follows: 1. 99283 – ED visit for E/M of patient with expanded problem focused history, expanded problem focused exam, and moderate level of medical decision making (MDM) a. I chose this code based on what I learned from Chapter 10 of 3-2-1 Code It! 2022 Edition. In that chapter, it shows you how to properly determine an E/M code based on the extent of history, extent of examination, and level of MDM [ CITATION Gre22 \l 1033 ]. For this patient record, I have determined that there was an expanded problem focused history and examination and a moderate level of MDM and as there are only 6 codes in the Emergency Department Services subsection in the E/M codes section, the code I chose includes the 3 key components of code 99283.
3 2. 71046 – Radiologic examination, chest; 2 views a. I originally search for chest x-ray and only received 3 results and I knew that none of those were the correct codes so I searched the “Browse codes” in Select Coder and realized I was searching for the wrong wording. I searched for radiologic examination chest and I received 9 results and from there I narrowed it down to 71046 since the notes specify 2 views of the chest. 3. 73502 – Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views a. I learned from the previous code the wording to search for, so I searched for radiologic examination hip and received 8 results. There were 2 codes for 2 views of the hip however the record specifies that they were performing the x-ray on the left hip, so I ultimately chose the code for unilateral x-ray rather than bilateral x- ray. 4. 81002 – Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrates, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy a. I searched Select Coder for urinalysis and received 10 results. The laboratory data for the urinalysis specifies dip stick only and this code has the attributes that work the best with the information given in the patient’s record. 5. 85025 – Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC, and platelet count) and automated differential WBC count a. I searched for complete blood count differential and received 4 results. Of the 4 results, there was only one that fit the patient record because the other codes included other laboratory tests.
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